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Cicatricial Ectropion Correction in the Inferior Eyelid with Cartilaginous Tissue

Graft: Case Report

Article · January 2014

DOI: 10.32457/ijmss.2014.026

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Int. J. Med. Surg. Sci.,
1(3):217-222, 2014.

Cicatricial Ectropion Correction in the Inferior

Eyelid with Cartilaginous Tissue Graft: Case Report

Corrección de Ectropión Cicatricial en el Párpado Inferior

con Injerto Libre de Cartílago. Reporte de un Caso

Aline Monise Sebastiani*; Guilherme dos Santos Trento*; Fernando Antonini*; Leandro Eduardo
Kluppel**; Rafaela Scariot**; Delson João da Costa** & Nelson Luis Barbosa Rebellato***

SEBASTIANI, A., M.; TRENTO, G., S.; ANTONINI, F.; KÜPPEL, L., E.; SCARIOT, R.; DA COSTA, D., J.;
REBELLATO, N., L., B. Cicatricial ectropion correction in inferior eyelid with cartilaginous tissue graft: Case
report. Int. J. Med. Surg. Sci., 1(3):217-222, 2014.

SUMMARY: Transcutaneous approaches of the lower eyelid are commonly used to provide adequate
exposure of the orbital floor and zygomaticomaxillary suture during treatment of facial fractures. Cicatricial
ectropion is a rare complication that results in a shortened eyelid. This condition can be temporary in some
cases but when it is permanent it must be surgically corrected, aiming to restore function, improve the
aesthetical outcomes and to prevent ophthalmological disorders such as epiphora and corneal ulceration.
The present study describes a novel surgical approach, associated with a concomitant cartilaginous graft, to
treat severe lower eyelid ectropion resultant from a previously performed subtarsal incision.

KEY WORDS: Ectropion; Postoperative complications; Cartilage; Nasal septum

INTRODUCTION

Ectropion is the retraction or eversion of blepharitis and hordeolum. Exposure of the

the ciliary margin in the opposite direction of
the eyeball and can occur in different degrees,
just as a point eversion with small scleral show
or with full rotation of the eyelid with the
conjunctival surface facing out (Eliasoph,
2005). Moreover, it can be classified as
congenital or acquired. The latter can be
subdivided into involutional, cicatricial,
mechanical and paralytic (Matayoshi et al.,
2004). Cicatricial ectropion is the result of
shortening of the anterior lamella (Veloso et
al., 2006) and is a complication associated with
transcutaneous incisions ofthe lower eyelid. As
a result of the lack of contact between the
eyeball and the everted lid, eyelid glands
become ectatic accumulating their secretions.
Consequently, keratitis can occur culminating
in corneal ulcer, chronic conjunctivitis,
tarsal conjunctiva can lead to hypertrophy and
keratinization of the conjunctival mucosa∏.
Furthermore, increased scleralshow is
unaesthetic and is frequently associated with
inadequate drainage of tears and excessive
dryness (Schaudig, 2012).
When this condition is permanent, it must
be corrected surgically. Surgical treatment of
severe ectropion aims functional and aesthetic
restoration, preventing ophthalmological
complications and improving facial appearance.
Among various techniques for correction of
ectropion (Eliasoph; Goel et al., 2013; Garza et
al., 2012) the use of an autogenous cartilage
graft to provide support to the eyelid has been
described (Carraway & O’Loughlin, 1994;
Krastionova et al., 2002).

*
Resident, Department of Oral and Maxillofacial Surgery at Federal University of Paraná (UFPR), Curitiba, Brasil.
**
Associated Professor, Department of Oral and Maxillofacial Surgery at Federal University of Paraná (UFPR), Curitiba, Brasil.
***
Chairman, Department of Oral and Maxillofacial Surgery at Federal University of Paraná (UFPR), Curitiba, Brasil.

217
 SEBASTIANI, A., M.; TRENTO, G., S.; ANTONINI, F.; KÜPPEL, L., E.; SCARIOT, R.; DA COSTA, D., J.; REBELLATO, N., L., B. Cicatricial ectropion
correction in inferior eyelid with cartilaginous tissue graft: Case report. Int. J. Med. Surg. Sci., 1(3):217-222, 2014.
The aim of this study is to demonstrate a
novel surgical technique for cicatricial ectropion
correction after a subciliary incision, through
grafting of cartilaginous tissue from the nasal
septum.
CASE REPORT
A 51 years old, leucoderma, male patient
presenting the left zygomatic-orbital complex
fractured, reporting being a victim of physical
agression (Figs. 1 and 2). He underwent surgery
under general anesthesia for fracture reduction
through intra-oral, supraciliar and subtarsal
incisions.
Fig. 1. Admission to Hospital with orbital fracture.
Fig. 2. Deficencie en vertex projection with a low level
in the left side.
During postoperative follow-up, gradual
eversion of the inferior eyelid margin was
218
observed. The patient was instructed to perform
massages in the region and was prescribed
ophtalmological ointment to prevent ocular
dryness.
After three months of follow-up, the patient
showed facial symmetry with good zygomatic
projection demonstrating correct fracture
reduction. However, clinical signs and symptoms
of permanent ectropion were evident (Fig. 3). At
this time, surgical correction was indicated.
Fig. 3. Ectropion after subtarsal approach.
Surgical Technique
Under general anesthesia, a 4cm maxillary
vestibule incision was performed to expose the
nasal floor and septum. After dissection, the
anterior portion of the cartilaginous septum was
clamped and removed (2x1cm) with the aid of
a Metzenbaumscissor. Simple continuous suture
was performed, using absorbable thread (Vicryl
3-0). After that, a left subtarsal incision was
performed (Fig. 4). Undermining just anterior
to the tarsal plate created a “pocket in the lower
eyelid. The graft was shaped like a semi-circle,
mimicking the lid (Fig. 5), and properly
positioned and sutured in the tarsal plate
extremities (Figs. 6 and 7). Suture was
performed by planes with 5-0 poliglactine
thread and later intra-dermal suture with 6-0
mononylon (Fig. 8).
Twelve months after the grafting procedure
on the left inferior eyelid, the patient had
adequate eyelid anatomy and function
performing complete sealing of the eyelids and
no aesthetic complaints (Fig. 9).
 SEBASTIANI, A., M.; TRENTO, G., S.; ANTONINI, F.; KÜPPEL, L., E.; SCARIOT, R.; DA COSTA, D., J.; REBELLATO, N., L., B. Cicatricial ectropion
correction in inferior eyelid with cartilaginous tissue graft: Case report. Int. J. Med. Surg. Sci., 1(3):217-222, 2014.

Fig. 7. Graft sustained over the tarsal plate.

Fig. 4. Surgical approach to make a cartilage free
graft.

Fig. 5. Cartilage from nasal area.

Fig. 8. intraoperative result after suture.

Fig. 9. One year follow-up

showing aesthetic result
and funcitonal situation
without ocular lession.

Fig. 6. Cartilege free graft put into the low eyeled.

DISCUSSION

Currently, there is a great discussion about
the advantages and disadvantages of
transcutaneous and transconjunctival access to
the orbital floor and infraorbital rim. Ectropion
is a complication that develops temporarily at
least in 28% to 42% of the transcutaneous
approaches to the orbital floor whereas the
transconjunctival approach has been reported
in less than 0.5%9.
For Wilson & Elis III (2006),
transcutaneous incisions provide the surgeon

219
 SEBASTIANI, A., M.; TRENTO, G., S.; ANTONINI, F.; KÜPPEL, L., E.; SCARIOT, R.; DA COSTA, D., J.; REBELLATO, N., L., B. Cicatricial ectropion
correction in inferior eyelid with cartilaginous tissue graft: Case report. Int. J. Med. Surg. Sci., 1(3):217-222, 2014.
adequate exposure without violating the lateral
canthal ligament. Holtmann et al., argue that
lateral canthotomy offers adequate surgical
exposure in transconjunctival access but inva-
des the skin, and the main objective of using
this incision is hidden scar. Lateral canthotomy
is often used during antransconjunctival
approach (56% to 83%). From researchs about
blepharoplasty (Spira, 1977; Spira, 1978; Rees
& Tabbal, 1981), the literature shows that
transcutaneous approaches have the advantage
of reducing the chances of injury to the ocular
globe or cornea and are less risky to the deeper
orbital structures.
Several authors (Rohrich; Feldman et al.,
2011; Bahr et al., 1992) agree that subtarsal
approach in comparison with subciliary approach
produce lower risk of vertical shortening of the
inferior eyelid and decreases the incidence of
scleral show and ectropion. According to Bahr
et al. this approach provides the most direct
and fastest way to the orbital floor compared to
others transcutaneous approaches.
Patients presenting inferior eyelid
retraction have in common the absence of
eyelid support causing an imbalance in the
forces that control their position. Common
causes of ectropion involve direct lacerating
injuries since when the laceration reaches
deep plans intraoperatively, thermal burns and
chronic sun exposure, and postoperative after
blepharoplasty. The pathogenesis of retraction
is multifactorial. However, the main factors
that cause retraction are deficient anterior
lamella or skin, scar retraction of the middle
lamella caused by local inflammation and
fibrosis after incision, and ligamentous laxity.
The vertical scar retraction of the middle
lamella leads to vertical entrainment of the
eyelid retractor muscles leading to lower
shrinkage with or without eversion of the
ciliary margin. As the septum retracts, it
shortens the distance between the ciliary
margin and the inferior orbital arc (Bahr et
al.). Presence of pellets and devitalized tissue,
loss of substance without replacement,
scarification of the eyelids, sutures poorly
made, neglect of post-operative care are some
factors that contribute to the occurrence of
ectropion after transcutaneous access
(Timoteo et al., 2009).
220
Evaluation of post-operative care of the
patient, consistent knowledge of periorbital
anatomy, proper use of existing surgical
resources, concern with function and fashion
are some variables that prevent the
development of ectropion after surgery
(Kanski, 2004).
The exposure arising from chronic
ectropion may result in keratinization of the
conjunctiva which contributes to ocular
irritation and can lead to vision loss. There
are specialized structures in the eyelids
promoting protection to the eyes, numerous
oils, mucus and aqueous producing-tears
glands present within the mucosal lining of
the tarsus – superior and inferior eyelid
conjunctiva. The blinking of the eyelids
distributes this complex forming a film on the
surface of the eyes (Bahr et al ., 1992).
According to Eliasoph, temporary palliative
treatments are essential for the protection of
the cornea.He recommends the use of artifi-
cial tears, ointments, eye protectors that retain
moisture and even temporary tarsorrhaphy,
among others. The patient presented in this
report was followed for three months
performing massages on the inferior eyelid and
making use of artificial tears, as long as no
improvement was observed, was considered
a permanent ectropion opting for surgical
intervention to correction.
Treatment with sutures, skin grafts and
even rotation flaps in the most serious cases
of ectropion are described in the literature
(Eliasoph; Goel et al.; Garza et al.) but is
confident that to return the appropriate eyelid
anatomy and function is necessary restore the
inferior eyelid intrinsic support which can be
accomplished by cartilaginous grafts. Carraway
& O'Loughlin described a technique using na-
sal septum cartilage to provide support for the
inferior eyelid structures attenuated,
emphasizing the importance of making the
release of the deep scar of the
capsuloligamentous eyelid fascia on the
dissection for graft implantation and thus
achieve ideal reconstruction. About 20 eyelids,
for a period of 12 years underwent
reconstruction of severe ectropion using this
technique. Reconstructive satisfactory results
with minimal complications were reported.
 SEBASTIANI, A., M.; TRENTO, G., S.; ANTONINI, F.; KÜPPEL, L., E.; SCARIOT, R.; DA COSTA, D., J.; REBELLATO, N., L., B. Cicatricial ectropion
correction in inferior eyelid with cartilaginous tissue graft: Case report. Int. J. Med. Surg. Sci., 1(3):217-222, 2014.

Krastinova et al. also described a technique of CONCLUSION

cartilage tissue graftingfor ectropion correction
using auricular concha as donor area, also
reporting success of the technique.In this case,
we opted for the removal of cartilaginous tissue
as graft. Postoperative recovery was uneventful
with the return of the appropriate eyelid
anatomy and function.
The technique of cartilage tissue grafting
from the nasal septum in inferior eyelid is a sim-
ple, safe and effective technique for the
resolution of postoperative permanent ectropion
of the inferior eyelid.

SEBASTIANI, A., M.; TRENTO, G., S.; ANTONINI, F.; KÜPPEL, L., E.; SCARIOT, R.; DA COSTA, D., J.;
REBELLATO, N., L., B. Corrección de ectropión cicatricial en el párpado inferior con injerto libre de cartíla-
go. Reporte de un caso. Int. J. Med. Surg. Sci., 1(3):217-222, 2014.

RESUMEN: El acceso transcutáneo del párpado inferior se utiliza comúnmente para proporcionar una
exposición adecuada al piso de la órbita y la sutura zygomaticomaxilar durante el tratamiento de las fractu-
ras faciales. Ectropión cicatricial es una rara complicación resultante de la reducción del párpado. Esta
condición puede ser temporal en alguns casos, pero cuando es permanentedebe debe ser corregida
quirúrgicamente con el objetivo de restaurar la función, mejorar los resultados estéticos y para prevenir
transtornos oftalmológicos tales como epífora y ulceración de la córnea. El presente estudio describe un
nuevo abordage quirúrgico, asociado con el injerto cartilaginoso concomitante, para tratar un grave ectropión
del párpado inferior resultante de la incisión subtarsal realizado anterior.

PALABRAS CLAVE: Ectropión; Complicaciones postoperatorias; Cartílago; Tabique nasal

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